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Diabetes can bring specific concerns when you are a woman, especially when it comes to your reproductive health including pregnancy. This helps ensure that you are closer to managing both these conditions with minimal possibility of an adverse outcome. Although not very common, diabetic ketoacidosis can pose risk for the fetus when experienced during pregnancy. During pregnancy, the decreased insulin sensitivity along with the catabolic state can promote diabetic ketoacidosis. Study shows that diabetes can cause fetal malformation and there is a direct association between HbA1C levels and the rate of malformation. In the study, HbA1C levels more that 10.1% showed neonatal malformation ranging between 20% and 25%. Search the NHLBI, use the drop down list to select: the entire site, the Health Topics section only, or the News and Resources section. This section of the Guidelines provides recommendations for pediatric care providers on managing cardiovascular (CV) risk factors in children and adolescents with diabetes mellitus and other conditions that predispose them to accelerated atherosclerosis. The evidence review for these Guidelines was designed to identify systematic reviews, meta-analyses, randomized controlled trials (RCTs), and observational studies from selected large longitudinal cohorts. The evidence review for these Guidelines identified only two studies relevant to CV risk reduction in children or adolescents with T2DM . In certain pediatric disease states, the process of atherosclerosis is dramatically accelerated, with clinical coronary events occurring in childhood and in early adulthood.
The Expert Panel recognized the importance of reviewing the evidence for these conditions so that appropriate recommendations could be made to guide pediatric practice.
In the first of these, a small number of children with advanced chronic kidney disease were treated with folic acid and placebo, and red cell folate levels, homocysteine levels, and FMD were compared.[48] On folic acid treatment, red cell folate levels increased, homocysteine levels decreased, and FMD improved significantly.
Children with T1DM or T2DM represent the prototype of the child at special risk for accelerated atherosclerosis and early clinical CVD. A very limited number of high-quality studies were found addressing CV risk reduction in children with conditions predisposing them to accelerated atherosclerosis, including diabetes mellitus, which is insufficient for development of evidence-based recommendations. The AHA statement recommends specific risk identification and management stratified by risk based on defined conditions that parallel the recommendations for adults with diabetes or other CVD equivalents (see Table 11?2). The Expert Panel believes that these recommendations should be used for the management of children and adolescents with diabetes and other conditions predisposing to the development of accelerated atherosclerosis, as outlined in the algorithm in Figure 11?1 and in Tables 11?2 and 11?3. The figure 11-1 is a flow chart with three different starting points, presented here as separate lists with numbered steps. For T2DM, intensive weight management and glucose control, in consultation with an endocrinologist as needed to maintain optimal plasma glucose and HbA1c for age. Assess body mass index (BMI), fasting lipids: Step 4 lifestyle management of weight, lipids for 6 months.
Assess BMI, BP, lipids, FG: Initiate Step 5 therapy, including statins, immediately in all patients age ? Antithrombotic therapy, activity restriction, ongoing myocardial perfusion evaluation per cardiologist. Diabetes is an amalgamation of many conditions which needs to be monitored carefully when pregnancy is on the way (or has already happened). It is very important that women planning to conceive control their blood sugar levels way before actual conception. Factors as decreased levels of plasma bicarbonate can be unfavorable for the body’s buffering capacity. Herein, a number of (structural) changes occur which can largely affect the kidney, sometimes even turning fatal. The evidence review did not address management of hyperglycemia, and this is not addressed in the recommendations.
The evidence review identified only two RCTs relevant to T1DM that met the inclusion criterion of having CV outcomes. The hallmark of T2DM is insulin resistance, which is strongly associated with obesity.[30] Among obese adolescents, insulin resistance has been reported in 16 percent of Caucasians, 27 percent of African Americans, and 26 percent of Hispanics.
A single systematic review addressing community-based lifestyle interventions to prevent T2DM in children included eight studies published between 1990 and 2001.[44] The interventions were all set in high-risk populations, and design problems included the absence of comparison groups and brief intervention periods.


Probably the best example of this is homozygous familial hypercholesterolemia, an extremely rare condition in which low-density lipoprotein cholesterol (LDL?C) levels are markedly elevated from birth due to the absence or near absence of functional hepatic LDL receptors. A separate category was created as part of the evidence review that identified potential relevant diagnoses and included Kawasaki disease, postorthotopic heart transplant, chronic kidney disease, nephrotic syndrome, human immunodeficiency virus (HIV) infection, and chronic inflammatory disease—all of which may increase the risk for early atherosclerosis and may require more aggressive control of CV risk factors. To maximize identification of T2DM in childhood and adolescence, the ADA screening algorithm is recommended for screening in all children (see Table 11?1). For the high-risk category, the disease process has been associated with clinical coronary disease before age 30 years.
90th percentile: Step 4 lifestyle management plus no added salt, increased activity for 6 months. Impact of diabetes on coronary artery disease in women and men: a meta-analysis of prospective studies. Non-insulin-dependent diabetes mellitus and fasting glucose and insulin concentrations are associated with arterial stiffness indexes. Aortic pulse-wave velocity and its relationship to mortality in diabetes and glucose intolerance: an integrated index of vascular function? Effect of type 2 diabetes and its duration on the risk of peripheral arterial disease among men. Regression of carotid atherosclerosis by control of postprandial hyperglycemia in type 2 diabetes mellitus. Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. The British Diabetic Association Cohort Study, II: Cause-specific mortality in patients with insulin-treated diabetes mellitus. Atherosclerosis in carotid artery of young IDDM patients monitored by ultrasound high-resolution B-mode imaging. Impaired vascular reactivity in insulin dependent diabetes mellitus is related to disease duration and low density lipoprotein cholesterol levels.
High prevalence of cardiovascular risk factors in children and adolescents with type 1 diabetes: a population-based study. Spectrum and prevalence of atherogenic risk factors in 27,358 children, adolescents and young adults with type 1 diabetes. Longitudinal lipid screening and use of lipid-lowering medications in pediatric type 1 diabetes. Effect of excessive weight gain with intensive therapy of type 1 diabetes on lipid levels and blood pressure: results from the DCCT. Advanced glycation end products are associated with pulse pressure in type 1 diabetes: the EURODIAB Prospective Complications Study.
Lipid and blood pressure treatment goals for type 1 diabetes: 10-year incidence data from the Pittsburgh Epidemiology of Diabetes Complications Study. Relation of body mass index and insulin resistance to cardiovascular risk factors, inflammatory factors, and oxidative stress during adolescence. Insulin resistance, hyperinsulinemia, and coronary artery disease: a complex metabolic web. Inflammation, insulin, and endothelial function in overweight children and adolescents: the role of exercise. Veterans Affairs cooperative study of glycemic control and complications in diabetes mellitus type 2. Lipid and glucose alterations in HIV-Infected children beginning or changing antiretroviral therapy.
Influence of puberty on endothelial dysfunction and oxidative stress in young patients with type 1 diabetes.
Early structural and functional changes of the vasculature in HIV-infected children: impact of disease and antiretroviral therapy. Being aware of the potential risks and outcomes is very important when you have diabetes and want to become (or already are) pregnant. Hyperglycemia (or high blood sugar) can adversely affect the growing fetus during the initial days which are highly crucial in its developmental stage.


Other factors including (upper) respiratory and urinary tract infections can further promote DKA. Another risk with diabetes is that of shoulder dystocia (in vaginal delivery) when the baby weighs more that 4000 g.
The section begins with background information on the importance of diabetes as a risk factor for CV disease (CVD). A randomized crossover trial in a small number of children with T1DM showed a decline in diastolic blood pressure during sleep with melatonin therapy.[28] The authors propose that melatonin be considered in trials to prevent the development of hypertension in individuals with T1DM.
Although type 2 diabetes is widely diagnosed in adults, its frequency has markedly increased in the pediatric age group over the past two decades.
On short-term followup, results indicated improvements only in knowledge and preventive behaviors. In this diagnosis, clinical coronary events begin in the first decade of life, and aggressive lipid management is needed.
Although data exist demonstrating a higher prevalence of early CVD and CV risk factors in conditions such as these, the evidence review for these Guidelines was designed to identify high-level studies, including systematic reviews, meta-analyses, RCTs, and observational studies from selected large longitudinal cohorts.[46],[47] Given the relatively small number of children with these diagnoses and the early stage of knowledge in this area, it is not surprising that the evidence review identified only three relevant RCTs, all in patients with chronic kidney disease. For the moderate-risk category, the disease process has been shown to be associated with pathologic, physiologic, or subclinical evidence of accelerated atherosclerosis.
Patients in the high-risk category require intensive management, with more aggressive goals for therapy than those in the moderate-risk category as outlined in the algorithm in Figure 11?1. Exercise training and the cardiovascular consequences of type 2 diabetes and hypertension: plausible mechanisms for improving cardiovascular health. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
Since the baby’s organs are mostly completed by 6-7 weeks after you had your last period, the significance of controlling blood sugar is right from the time when you plan to get pregnant. This is coupled with the risk of preeclampsia in pregnant women having diabetes which is likely to aggravate the tendency of renal damage. This is followed by the Expert Panel's summary of the evidence review relative to diabetes, separated for type 1 and type 2 diabetes mellitus, and then by a subsection on other predisposing conditions. T1DM presents at a younger age, with 25 percent of patients diagnosed between ages 5 and 10 years and another 40 percent between ages 10 and 15 years. In children with T1DM, administration of folate and vitamin B6 each led to immediate normalization of FMD, which was sustained at 8-week followup.[29] Findings suggest that, in the setting of T1DM with a high risk for vascular disease, folate and B6 therapy could be beneficial, but the findings in these two trials have not been duplicated.
The evidence review and the development process for the Guidelines are outlined in the Section I. If not treated adequately, the degree of hyperglycemia is severe, and patients are highly symptomatic. Diabetes, another high-risk diagnosis, is addressed above, but there are other conditions in which the risk of accelerated atherosclerosis is known to be high, that are not necessarily identified in a risk factor-based evidence review such as the one preformed for these Guidelines.
As described, the evidence review augments a standard systematic review, where the findings from the studies reviewed constitute the only basis for recommendations, with each study described in detail. Step 5: For tier II, if goals are not met, consider medication per risk factor specific recommendations in these guidelines.
This evidence review combines a systematic review with an Expert Panel consensus process that incorporates and grades the quality of all relevant evidence based on preidentified criteria. Because of the diverse nature of the evidence, the Expert Panel provides a critical overview of the studies reviewed for each risk factor.
Following its review of the limited available evidence for this subject, the Expert Panel elected to employ expert opinion by expanding on the recommendations of the 2006 guidelines from the American Heart Association (AHA),[1] which addressed CV risk management in high-risk pediatric patients, including those with diabetes. This approach is described in detail in this section, relative to the management of other conditions predisposing to the development of accelerated atherosclerosis.
References are listed sequentially at the end of the section, with references from the evidence review identified by unique PubMed identifier (PMID) number in bold text.



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